Pioneering the Health Care Quality Improvement in ...

Journal of Cases on Information Technology, 14(4), 41-55, October-December 2012 41

Pioneering the Health Care Quality Improvement in India Using Six Sigma:

A Case Study of a Northern India Hospital Anuj Kapoor, Punjab University, Chandigarh, India Rahul Bhaskar, Steven G. Mihaylo College of Business and Economics, California State University, Fullerton, CA, USA Au Vo, Claremont Graduate University, Claremont, CA, USA

EXECUTIVE SUMMARY In India, the notion of Health Care Quality has become a relevant topic. Even though Quality Management processes such as Six Sigma have been proven in the health care industry in the United States, there is little record of Six Sigma implementation in India. Despite the lack of proven success in the country, Simplified Health Care, a prominent health care provider in North India, launched successful Six Sigma implementation, which was supplemented with other IT initiatives including Electronic Health Care Records. Simplified Health Care success is a testament for Six Sigma, despite challenges ahead. Keywords:

Electronic Health Care Records, Health Care, India, Quality Management, Six Sigma

ORGANIZATIONAL BACKGROUND Simplified Health Care (SHC) is a subsidiary of Simplified National Corporation. Simplified National Corporation is a private and publicly traded company which trades over 30,000 shares in the Bombay Stock Exchange. Simplified National Corporation specializes in health care and related products. Besides SHC, Simplified National also owns and operates subsidiaries in three different industries, namely life and health

care insurance, clinical research, and medical equipment manufacturing. Even though all four entities bear the name Simplified, they work separately with each other. Structurally, SHC is the largest health care employer in New Delhi and other cities of northern India. It has over 200 doctors and physicians, 1,500 registered nurses, 6,500 full and part time employees. SHC serves a community of more than 15 million inhabitants. At its peak, SHC served more than 1,700,000 patients. SHC was planning to extend its inpa-

DOI: 10.4018/jcit.2012100104 Copyright © 2012, IGI Global. Copying or distributing in print or electronic forms without written permission of IGI Global is prohibited.

42 Journal of Cases on Information Technology, 14(4), 41-55, October-December 2012

tient capabilities, growing the number of beds to 2,000 in 2012. SHC offers both general and specific health care services, ranging from routine check-up to cancer detection and treatment. All four hospitals, which are located in Delhi and surrounding National Capital Region area, offer a full range of services in primary care. In addition to the hospitals, SHC operates various hospices and health care centers throughout the region. In Panchsheel Park and Noide, SHC runs Simplified Eye and Dental Care and Vascular and Neuro Sciences Institute respectively. In Pitampura and Saket, SHC organizes secondary care facilities along with Cancer Center and Center for Pediatrics. In addition, SHC also has tertiary care at Gurgaon and Patparganj. In Shilmar Bagh, orthopedics surgery is a tertiary care of SHC that focused on spinal and sportrelated injuries (Figure 1). Founded in 2000, SHC is arguably one of the state-of-the-art facilities. With $250 million (USD) in assets, SHC boasts of being one of the well-funded health care systems in India.

All SHC hospitals have been certified with ISO 9001:2000 standards. The specialty hospices have been earned a national recognition and various awards. In spite of these achievements, SHC has not enjoyed much success financially. SHC struggled in 2008 with $1 million in loss but recorded a profit of $9.5 million in 2009. The situation changed again: despite a 20 percent growth in 2010 and 2011, SHC sales and operating revenue was stagnant. In 2012, SHC recessed into a slump with more than $6 million in loss. SHC has a simple organizational structure. The top leader is a Managing Director (MD) who acts as a liaison between SHC and Simplified National Corporation. Under the MD, the CEO oversees the entire SHC operations direction and strategy. In addition to the CEO, there is a CFO, a CSO (Chief Services Officer), a CMO (Chief Medical Officer), a COO, and an Executive Director. On the clinical side, the CMO manages a wide range of medical specialties, ranging from neurology, neurosurgery to obstetrics. Each specialty has a Director, who

Figure 1. Delhi map (Maps Of India, 2013)

Copyright © 2012, IGI Global. Copying or distributing in print or electronic forms without written permission of IGI Global is prohibited.


in turn has a Chief of Staff reporting to him. Altogether, there are 24 different specialties in SHC. The Director of Information Technology reports to the Chief Services Officer (Figure 2).

SETTING THE STAGE Health Care in India India’s health care sector is poised to grow at an annual growth rate of 12-15 percent in the period between 2010 and 2020, making it the largest sector in absolute terms for both revenue as well as employment generation (Bakshi, Prathipati, Sriram, & Vaidya, 2010) . With the latest estimates, the healthcare sector is expected to grow from $34 billion in 2007 to nearly $40 billion by 2012, with majority of growth coming from the private sector. (PricewaterHouseCooper, 2007). The reasons of mushrooming private healthcare institutions in an emerging economy like India can be explained in terms of two viewpoints: Consumer and Hospital. From the consumers’ perspective, urbanization and emergence of a new middle class with aspirations, demands, and awareness about their health needs are important. From the hospital

perspective, quality is becoming extremely important. Bakshi et al. (2010) forecasted the coming up of age of “Healthcare 3.0” in India, in which revenues of private players in hospitals would be linked directly to the patient satisfaction. These factors, combined with the legal obligations, will lead a shift to hospital focus towards quality of care. Increasingly, there is low tolerance for queues and long waiting hours in healthcare institutions. On the other hand, there is a rise in both infectious and chronic degenerative diseases. Along with ailments due to lifestyle, all these factors have contributed significantly to the growth of private health care hospitals in India. The rise in the medical errors that is prevalent in the health care industry are one of the major concerns for SHC. Medical errors, as defined by the Institute of Medicine (1999) are “the use of wrong plan to achieve an aim”. Medical errors can be categorized into four different types: diagnostics, treatment, preventive, and other issues such as systems and equipment failure (Institute of Medicine, 1999). At the least, medical errors can cause discomfort for patient, and spiral the hospital costs. In the worst scenario, it can cause loss of life. As a comparison, in the Institute of

Figure 2. Simplified health care organizational chart



Medicine’s report, United States observed between 44,000 to 80,000 deaths each year due to medical error (1999). Contrary to the United States, where physicians and hospitals claim health care expenses from the payer company, in India, besides paying the insurance premiums, the insured pay out of pocket expenses for health care services and then seeks reimbursement thought the insurance company (Columbia University, 2012). Furthermore, out of pocket expense accounts for 70 percent of India national health care expenditure (National Health Accounts - India, 2004). For that reason, only the middle and upper classes in India is able to purchase the health care insurance and have access to premium health care service. Health care institutions are upgrading their infrastructure and developing tools and methods in an effort to control costs and increase revenue without sacrificing the quality of care. Six Sigma could play a major role in transforming the health care institution in business and quality control processes.

An Introduction to Six Sigma Originally developed in the manufacturing sector, Six Sigma is the process of controlling the quality of products produced. Motorola has introduced Six Sigma in 1986, using Japanese quality control processes (Tennant, 2001). Six Sigma is a proactive approach in finding and eliminating the production problem. Despite the common beliefs, achieving “Six Sigma” quality is not the goal of implementing this process. In fact, Six Sigma integration requires a company to implement a working quality control program to detect and eliminate defective parts and employ a new process in which the same defects would not reoccur (Harry & Schroeder, 2005). The science of Six Sigma is based on a statistical and data-driven methodology to pin-point the problem (Blakeslee, 1999). Since its inception, Six Sigma has transformed the manufacturing industry. From 1986, the year when Six Sigma was introduced, to 2000, Motorola profited $16 billion due to the successful Six Sigma implementation (Eckes, 2000). The idea is to achieve perfection, “six”

sigma, which is defect in four parts per million (Blakeslee, 1999). Six Sigma employs two structured methodologies: DMAIC and DMADV. While DMAIC is used primarily for existing business needs, DMADV is used to create new product and services embedded with Six Sigma philosophy. DMAIC is an acronym for Define, Measure, Analyze, Improve, and Control and DMADV is an acronym for Define, Measure, Analyze, Design, and Verify (De Feo & Barnard, 2005). In the context of this case, we focus on DMAIC process. In DMAIC, the first phase, Define, is used to identify characteristics of processes and products that are in need of improvement. Critical performance benchmarks are also specified in the Design Phase. In the Measure phase, relevant data is collected. In the Analyze phase, the organization conducts a drill-down investigation the current processes against the benchmarks and determine the sources of defects. Once the problem has been analyzed, improvement processes are proposed, designed, and tested in the Improve phase. Finally, in the Control phase, control protocols and systems using statistical tools are in place to make sure that the deviation from the solutions is minimal (Shroeder, Linderman, Lidtke, & Choo, 2008).

Six Sigma Certification Systems In Six Sigma, the certification system is broken down into a belt system. Similar to that of martial arts, there are several belt colors associated with different levels of mastery. The Six Sigma Champion holds the Master Black Belt, and is dedicated in ensuring the successful adoption of Six Sigma in the organization and its vision. The organization executives who are in charge of Six Sigma projects are Black Belts. Green Belts are individuals who are involved in data collection and data analysis. Yellow Belts provides an insight to the techniques of Six Sigma, its metrics and improvement methodologies. White Belts are team members who are aware of Six Sigma and understand its concept and methodology at a nascent level (American Society for Quality, 2013). While Green-belt-level and below hold a lifetime certification, Black Belts are required



to renew their certification every three-year (American Society for Quality, 2013).

Six Sigma and the Health Care Industry Though originating in the manufacturing industry, Six Sigma and Lean Sigma have been transformed to work in the service industry. The benefit and outcome of transforming using Six Sigma is a realized saving of $1.5 million and a reduction of complaints in half (Antony, Antony, Kumar, & Cho, 2006). Other service industries including banking, logistics, and financial services also achieved greater quality control using Six Sigma. Contrary to the common beliefs, the health care industry is familiar with Six Sigma and its impact in the organization and the industry. At Kentucky’s Commonwealth Health Corporation, the radiology department was high in cost and low in throughput. Six Sigma has helped Kentucky’s CHC improve radiology efficiency and reduce one third for each radiology procedure (Thomerson, 2001). At the Froedtert Memorial Lutheran Hospital in Milwaukee, Wisconsin, laboratory and medication errors were the culprits in jeopardizing patient’s health and safety. The implementation of Six Sigma resulted in the saving of $1.2 million and 22 percent cost reduction in the radiology procedure (Buck, 2001). Furthermore, North American Medical Management – California, Scottsdale Health Care – Arizona, Charleston Area Medical Center - West Virginia were some of the additional examples of Six Sigma implementation (Revere & Black, 2003). Most notable was Common Wealth Corporation in Bowling Green, Kentucky. It was one of the first pioneering health care organizations to make a strong commitment to Six Sigma in 1998 (Yilmaz & Chatterjiee, 2000). Even though Six Sigma successful implementation has been well-documented, there is little research about its failure. Antony (2006) warns about potential challenges and difficulties when implementing Six Sigma in the service industry. One of the common challenges is the lack of responsiveness in collecting feedback

from the consumers. Sehwail and Deyong (2003) also warned about defining what is appropriate to be defined in the service industry as Six Sigma standard, which is four parts per million defects. Another challenge, as Antony (2006) pointed out, is the uncollectable data due to unquantifiable human interaction such as friendliness and courtesy. Furthermore, Six Sigma is a long term commitment from every single entity of the organization. Using a topdown approach could result in failure, for it would create remorse amongst the employees. Keeping the employees committed to Six Sigma in the initial period is often a key for successful implementation (Wageman, 1995). In India, the notion of improving quality management processes in health care is starting to unveil. Varkey and Kollegonde (2011) proposed a framework for using Lean Sigma to improve Health Care in India. In 2007, a South Indian hospital succeeded in utilizing a Total Quality Management program based on the Malcolm Baldrige National Quality Award (Manjunath, Metri, & Ramachandran, 2007). Though the executives unanimously agreed that SHC was in need of an overhaul, they were still very skeptical about Six Sigma. After reviewing success stories and anticipating the potential challenges, the executives voted for Six Sigma as a catalyst for improving quality.

CASE DESCRIPTION As the Six Sigma integrator, Max, who was brought into SHC in 2011 because of his experience in managing Six Sigma in the services industries overseas, designed Six Sigma methodologies and metrics for SHC.

Methodologies Based on the DMAIC steps which were used for process improvement, Max concluded that the first step is to reduce the range and variation in the process time and cost before upgrading the capacity. During the first 2 years, Max has trained more than 100 Six Sigma certification holders. He tallied roughly 8 black belts, 20



green belts, and more than 100 yellow belts across multiple functions. In conjunction with the Executives and the Board of Directors, Max has developed an in-house definition for Health Care Quality at SHC. In the official document, Max defined Health Care Quality as followed: 1. To SHC, Health Care Quality is the ability to utilize technological sophistication or therapeutic efficacy to help deliver the maximum and correct treatment to the right person at the right time. 2. To our patients, Health Care Quality would be perceived as (A) professional competency (B) system effectiveness (C) service excellence and (D) amenities. Following this manifest, Max decided to focus on aspect of cost reduction in projects for better services to meet both providers’ and patient’s expectations.

Criteria of Choosing Improvement Projects Using Six Sigma, SHC has derived a welldefined Service Quality model in SHC which is given in Figure 3. In this model, process was laid down to meet the customer expectations, as well as

documented to allow it to be replicated across all SHC Hospitals. The Critical to Quality (CTQ) parameters measured the patient needs. Side by side Value Stream Mapping (V.S.M) is performed to find out all the value added and non-value added activities in the process. Gaps between the services expected by the customer and services delivered to the customer is measured and analyzed with the help of statistical tools and different methodologies embedded in Six Sigma continuous improvements were made in the process and voice of customer was reviewed to optimize the impact and control for new processes.

Adoption Phase The Critical to Quality parameters produce dashboards, Total Customer Experience Questionnaire (TCEQ). As its name suggested, TCEQ was a feedback program that helped in identifying the areas that need improvement. Based on the predefined metrics, consistently poor scoring areas would be converted into a potential improvement project in Six Sigma. By sifting through approximately one hundred parameters across multiple functions, this performance measurement process was unique to SHC in Indian health care sector, and was used to measure SHC’s own performance as per the process capability.

Figure 3. Criteria for choosing improvement projects in SHC



Through Value Stream Mapping (V.S.M), all the concerned areas were identified which were primarily reflected through TCEQ. Since there are 40 areas that were identified as needing immediate attention. Customer touch points, including but not limited to security, outpatient department, dietary facilities, diagnostics and prognostics, and pharmacy were evaluated. Since the inception, the TCEQ dashboard provided SHC with several areas of improvement. Both clinical and non-clinical problems were presented to SHC executives. SHC was skeptical of Six Sigma and did not want to commit fully. After analysis, SHC decided to initiate Six Sigma implementation at the non-clinical spectrum first. At that time, the rationale was to use non critical functions in the non-clinical areas as an implementation prototype where the risks are minimal. The focus was to reduce the variance between patients’ transaction time. For instance, a patient experienced sporadic waiting time in an outpatient department. The wait time might vary between 10 minutes and 60 minutes. The variation of timing in two visits (50 minutes) had a larger effect on the patient (Table 1).

Details of the Projects Involving Six Sigma Business Management Strategy Undertaken at Simplified Health Care (SHC) The Pharmacy department volunteered to become the original department with Six Sigma adjustment. Max maximized this opportunity to present the immediate impact and benefit of Six Sigma implementation to SHC. The details of each DMAIC steps and the success are documented below.

Increase Dispatch Capacity in Pharmacy Risk Analysis There were many shortcomings in the pharmacy processes: •

•

The request from the different pharmacies increased day by day and the CPS (Central Pharmacy Store) was unable to cater to the demands. Due to patients’ inability to get the medicine per their requirements, the patients had a huge dissatisfaction, hampering the objective of the organization. The problem also contributed to declining revenue and shrinking of current patients.

Table 1. Key clinical/non clinical projects around processes across all functions at SHC Function

Project Focus

Pharmacy

To improve capacity of dispatch system and reduce procurement cost.

Medical Quality

To decrease the rate of CRBSI (catheter related blood stream infections).

Nursing

To optimize workload between pharmacy and nursing.

Housekeeping

To standardize and consolidate OPEX items Pan-Max.

Diagnostics

To optimize diagnostics pricing.

Food and Beverages

To increase customer satisfaction involving Food and Beverages

Information Technology

To reduce printing and stationary cost

Engineering and Maintenance

To reduce noise levels



•

Negative feedback multiplied in the vicinity, causing loss of potential patients for SHC.

To overcome these threats and minimize further damage, SHC decided to take up Six Sigma project which would help increase the dispatch capacity of CPS.

Methodology As a part of Six Sigma, DMAIC methodology was used. Different steps of DMAIC that were used in pharmacy project are given below.

Step 1: Defining the problem The Voice of the Customers (VOC) analysis for six months revealed that the key contributors to this problem were: 1. 2. 3. 4.

Low stock of medicine Medicines not reaching on time Need to increase stock variety Low dispatch rate from CPS

The CTQ drill down highlighted dispatch capacity as the problem area which needed focus. The existing process from CPS was as shown (Figure 4).

Step 2: Data Measurement The current performance of dispatch rate for the Central Pharmacy Store was measured and the total number of issues per day was calculated

against the total number of indents for each local pharmacy. Additionally, time and motion study was done for the resources allocated for each activity. The average dispatch capacity from central pharmacy store to unit pharmacies was calculated as 45557 Quantity / day (AveragePre-Project) and improvement target was set as >=60000 Quantity / day (Average-Post-Project).

Step 3: Analysis The Fish Bone diagram (a tool in the DMAIC Training Material) in Figure 5 for the process showed the following bottlenecks: 1. Machine: a. Transportation: Route planning and schedule for dispatch of material were not followed, creating bottlenecks in the process b. Packaging: Wear and tear of packages as carton boxes were used. Also there was no visual differentiation between in-coming and out-going material. 2. Manpower: a. Workload Distribution: There was no proper workload distribution as there were two separate shifts and at peak hours there were fewer resources. 3. Method: a. Unscheduled Indenting: There was no schedule for units to indent the medicines. b. Batch Process: One indent was responsibility of every person in CPS

Figure 4. Pre-project process flow



Figure 5. Fish bone diagram before implementation

as there was batch process for issuing the material. This lead to long wait for medicines at units. c. Manual Indenting: The Manual practice of indenting involved a lot of rework at both ends and was long and tedious. 4. Material: a. Space Utilization: There was improper stacking of material in the stores. This was resulting in non-utilization of space along with no segregation of areas for dispatching and receiving.

Step 4: Implementation SHC analyzed the current situation following action points for implementation was laid (Figure 6):

•

•

•

All the unwanted material in the CPS was removed from site which resulted in proper access to the medicines which now can be managed with less effort and lesser time. Also the height of the racks which were used to stack the material was also adjusted so that more material could be stacked in the same place; this solved the problem of improper stacking. After brain storming, the target dispatch capacity was set as 32 percent of the present dispatch rate in 2 months. Data tracking and monitoring was done throughout the implementation stage to ensure there were no deviations. Manual indenting was stopped by auto indenting which was implemented across SHC.

Figure 6. Post project process flow



•

•

•

• •

•

By proper route planning and schedule for dispatch of material, dispatch was more streamlined and made robust which made it more user-friendly. Initially, there were two shifts: one from 8am to 4 pm and the second from12 pm to 8 pm. It was decided to merge the 2 shifts into 1 general shift for enhancing the efficiency of the work force. For better segregation between incoming and outgoing material, different color coding of plastic boxes was done. This facilitated trouble free handling and transportation. The available resources were realigned to suit the current requirement while keeping the availability of the resources in mind. Color coded transaction enhanced the visual controls. Changing color into green for dispatch, yellow for receipt, and red for discard items has boost the productivity and traceability. Size and quality of cartons were simultaneously worked so that more material could be handled without any wear and tear after doing proper cost-benefit analysis.

Step 5: Control Plan Control plan ensured that the process changes were sustainable in the future with the main objectives of plan being: 1. To ensure that once the solutions have been implemented, the process remains in place. 2. To detect and determine the root cause of out-of-control state and assimilate a plan to correct the problem before non-compliance started.

Results The queue management system resulted in an increase in dispatch capacity of central pharmacy to satellite pharmacies by 37 percent, more than the target of 32 percent. The post project analysis of patient feedback revealed

an immediate impact of 12 percent increase in customer satisfaction and reduced negative customer comments. The project also had an overall positive impact on the revenue reflected with one-third increase in Pharmacy revenue,

The Proliferating of Six Sigma Projects at SHC As a result of the success, other Six-Sigma-inspired projects are carried out across functions. Below are the brief description and results of some prominent projects. 1. Pharmacy: Finding a generic medication comparable to the name brand medication has been a challenge in India. A study was conducted based on each manufacturer to evaluate their consumption value. The study reduced the list of suggested manufacturers and compiled a list of possible substitute medication, which would be approved by the Chief of Staff in each medical specialty. The Chief of Staff then negotiated for a restructuring with a smaller list of suppliers. Before the implementation, medication profit margin was 30 percent. The profit margin increased significantly to 49 percent and process sigma figure is more than doubled. 2. Medical Quality: In SHC, one of the most infection observed by the physicians are the catheter-related bloodstream infections (CRBSI). The infection occurred is crucial in hospital quality metrics, for it is a major reason that causes morbidity and mortality in the hospital. Once a major complication has been developed, patients have little hope to survive. Due to the urgency of the problem, Medical Intensive Care Unit (ICU) is in need of Six Sigma implementation. By assimilating multi-disciplinary team members, the team set a focus of reducing the CRBSI rate. During the Define state, the team collected data on infected patients during their stay. By mapping out the



fishbone diagrams, the team was able to identify several critical preventive steps to achieve the desired outcome. Seeing the need for retraining the nurses and the physicians, the implementation team initiated a training session with educational videos and practical observations. The training session is also being scored based on its effectiveness and it would be adjusted accordingly. 3. Nursing: Nursing is often viewed as the most crucial internal customers for Pharmacy. Despite the common interaction, Pharmacy was unable to fulfill the entire nursing request. There are a plethora of drugs and comparable medication in which the pharmacy don’t carry while the nurse insisted on using the exact brand. As a result, the process was bogged down in lieu of high turnaround time. To alleviate the issue, Pharmacy and Nursing concerns was accumulated and brought into a brainstorming session, where both departments worked in conjunction with a Six Sigma team to address concerns from both departments. In the brain-storming session, the pharmacy worried about their overused indent-load, while the Nursing stressed the sluggishness of dispensing medication. The report pinpointed the root cause of the problem is duplication of work in both departments. It is further concluded that almost a third of the requested items was duplicated. After the session is adjourned, a consensus plan of standardization would be in place. It stressed three points: a) classify each indent in Normal/ Routine/ Urgent categories for optimizing turnaround time, b) each patient has 1 indent for routine medicines as opposed to 1 indent per patient per medicine, and c) returning of medicine is administered at off-peaks hour to ameliorate errors. The implementation has been enjoyed for both departments. The process sigma is doubled to 4 after changes are in place, and the indented medication rate is reduced to 5 percent. Not only SHC has boost the efficiency of the process, SHC also eliminates medication

dispense errors and increase productivity in both Nursing and Pharmacy. 4. Housekeeping: The procurement cost for the housekeeping items was very high due to the inconsistencies in the buying processes. The team worked on the root causes which induced variation in the procurement of the housekeeping items based on cost, brand and supplier as the critical factors. Identification of all possible solutions for all the root causes were brainstormed and best possible solution was implemented. 5. Diagnostics Pricing: Customer feedback analysis disclosed that variation in pathology test pricing with in units caused dissatisfaction. Tests were prioritized for standardization based on their contribution by volume using 80-20 rule. After Proper market analysis and benchmarking analysis tools like Pareto, fish bone, and regression analysis were used to optimize prices for identified pathology tests which resulted in doubling of same pricing region wise and 75 percent at SHC along with the increase of process sigma along with substantial financial gain from the project. 6. Food and Beverages: The problem based on the TCEQ data was the lower customer satisfaction as per the services of Food and Beverages is concerned. The SIPOC was made to understand the entire process from which it was concluded that the key areas of concern were adherence to time schedule, food temperature, clearance of utensils, communication /staff response. Floor wise catering time schedule was revised as per the process capabilities. To keep the food warm, temperature settings were done so that it could be served at optimum temperature to the patients. To fasten clearance time and effective use of resources, check sheets were used. Customer satisfaction level has increased substantially after this project. 7. Reduce Printing and Stationery Costs: To reduce printing and stationery costs, problems identified were complex storage and retrieval process, high stationery cost,



high storage and retrieval cost. Average cost per month on account of printing and stationery for the printouts pertaining to various transactions was high. The cost involved on account of photocopies and storage of dockets pertaining to Finance involved high costs. After thorough brainstorming, root causes were analyzed. Solutions identified were the use of alternate printing mechanism and using soft copy instead of hard copies to store the customer information. This resulted in a significant saving and ease of handling information. 8. Engineering and Maintenance: Many VOCs were being reported including noise in the corridor, loads of noise due to food and beverages services and the patient movement in the corridor. To address this issue, noise level in different parts of the hospital at different point of time throughout the day were analyzed and noise sources were identified and segregated as per the significance to the customer. Noise levels outside patient area as well as inside the patient rooms were analyzed. Also, high variation of noise level was seen in various areas ranging from 45.6 dB to 87.2 dB. Then “defects” were analyzed as noise level which was above the target as per the Hospital norms. All possible Engineering and behavioral aspects were taken care of, for the changes to me made. Significant improvement in the sigma levels were reported at the end.

Supplementing Six Sigma Initiatives with Electronic Health Care Records For supplementing the Six Sigma initiatives which dealt with service and operational excellence along with standardization of service across all its locations, Simplified decided to focus on enhancing the technology backbone by embracing Information Technology initiatives for improving continuity as well as quality of patient care. However, the technological supplement has encountered some setbacks.

Doctors explicitly voiced their concerns about paper records, which they primarily rely on as opposed to digital records. Despite the familiarity of the paper records which increase doctors and physicians effectiveness, paper records are moribund. Paper records cannot be used in order to comply with ICD and CPT records. In addition, paper records are immobile. It tends to stay at one place until it has been physically altered. Doctors, on the other hand, are mobile and in need of the correct information on their fingertips. Paper records also impede the effort of aggregating patients’ data for faster retrieval. Such delays might significantly decrease quality of care. Thus SHC decided to implement an open source Electronic Health Record solution – WorldVista. Customizing WorldVista according to SHC requirement will be done in concurrent with upgrading the in-house developed Hospital Information System. Both will be linked with an HL7 interface engine for Electronic Medical Record integration. In turn, the system would interface with Laboratory, Radiology and Pharmacy. SHC also utilizes Computerized Patient Record System (CPRS) for documenting, ordering, reporting and viewing of clinical information was introduced. Configuration of Alerts, Clinical reminders and Clinical Transformation including process re-engineering was planned and executed along with a standard of minimum patient data set. A large number of trainings and re-trainings were conducted as part of change management process. The new system would aid the Doctor to document the patient record using standard terminologies like ICD and CPT. The record would abide to a structured set of data using standard templates. In addition, the system would be able to recognized scanned documents from both internal and external sources. This recognition would aid in keeping the best medical records for the most accurate care. The collaboration on patient care for a faster second opinion was enhanced with Desktop collaboration across locations using implementation of unified communication solution, also referred to as System Access at



the Point of Care via Wi-Fi environment and COW’s (Computer on wheels). An m-health system for accessing laboratory reports and Radiology images was also implemented for improving turnaround times of starting care plans. This supported the emergency room which aggregates the knowledge and wisdom of specialists around SHC to give the on-call physicians a second or third opinion. Similarly, oncology patients in distant hospitals under the care of oncologists can get a real time second opinion from top level Onco-surgery superspecialists located at Saket/other locations. All of these technologies came together for this requirement where complete clinical records in the EHR (such as progress notes, orders, drug charts, vital charts) were used in parallel with a video communication on the COW next to the patient’s bed. The diagnostics reports together with imaging on mobile devices enabled doctors to respond faster to the patients to support quicker care delivery. The super-specialist could provide faster second opinion from anywhere/ anytime for even the trauma patients, leading to an increase probability of saving lives.

Amidst of Six Sigma transformation, changes would hamper the organic growth of the organization. Change resistance would proliferate and organization culture will be impeded. In addition, technological advancement would also put pressure to the organization. Finding the balances between changes, growth, and transformation would be one of the challenging tasks for SHC. Finally, Six Sigma Belts holders are limited, especially black belts. They are often the current employees of a specific function. Black belts holders, which are the senior managers of the company, at times were occupied with other important organizational projects. Furthermore, SHC has not fully invested in Six Sigma yet. Max needed to build a strong reputation to show the executives the values of Six Sigma. Achieving the trust and commitment of upper management would help Max create a set of Six Sigma team, in which the only focus is to improve and enhance SHC efficiency and quality using Six Sigma.

CURRENT CHALLENGES FACING THE COMPANY

Implementing new methodology and ensuring success was a challenge in itself for Simplified Health Care due to cultural reasons. In addition, management would like to realize immediate positive impacts. Therefore, success implementation in simple areas is encouraged, where there are minute dependent factors and minimized incurred costs. Further implementation into more difficult areas will soon commence. Simplified needs to embark upon the same strategy for future projects involving combination of Six Sigma and complement it with Information Technology initiatives. Also SHC needs to come out with a clear cut and neatly defined mission statement and goals for the project before embracing any new project. This need to be complemented with periodic reviews to be done mandatory by various levels of management at periodic intervals which means involvement of Six Sigma exponents at all levels, right from white belts to master black

As SHC is reaping the benefits of Six Sigma, Max acknowledged that his work has only begun. Six Sigma needs a total focus and coordination from the entire organization, and it would be monumental to instill the Six Sigma philosophy into SHC staff. Facing with these imminent issues, Max are headstrong in finding the solutions. First of all, SHC separated the clinical and non-clinical aspects and solved them independently. Initially, the classification provided a clear and concise direction. However, as the transformation is underway, the line between clinical and non-clinical should be ambiguous. Therefore, a tentative plan should be in place and executive if needed. SHC would not be able to achieve desired results unless both of these aspects are addressed concurrently.

CONCLUSION



belts at all stages of execution. This would help in changing the mindset of Six Sigma exponents and also removing their aversion towards embracing information technology initiative from manual ones as it will be difficult to ensure successful implementations. Management commitment needs to be hundred percent and project need not be started unless there was a solid buy-in to start one. With SHC being the first institution in India to opt for large scale Six Sigma implementation and complement it with Electronic Health Records, future quality improvement initiatives could slot into the current arrangement, without major changes to the existing system.

De Feo, J., & Barnard, W. (2005). Juran institute’s six sigma breakthrough and beyond - quality performance breakthrough methods. New York, NY: McGraw-Hill.

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Anuj Kapoor holds a Bachelor of Technology degree in Mechanical Engineering from University Institute of Engineering & Technology, Kurukshetra & is currently pursuing his MBA with International Business & Marketing as specialisation from University Business School, Panjab University, Chandigarh. His research focuses on Marketing Strategy with a specific emphasis on Branding, Product Innovation, marketing-finance interface & Six Sigma. Rahul Bhaskar is a Professor of Information Systems and Decision Sciences at the Steven G. Mihaylo College of Business and Economics, California State University, Fullerton. He holds a PhD in Management Information Systems from University of Madison, Wisconsin. Dr. Bhaskar’s experience spans across diverse industries. He is experienced in revenue management, big data, data warehouse, and business intelligence. He has been a recipient of grants from the Department of Homeland Security and other private institutions. His expertise is in data analytic, business intelligence, cyber terrorism, marketing information systems, and health care information systems. Au Vo is a Claremont Graduate University PhD National Scholar. He is a recipient of the prestigious merit-based Claremont National Scholarship. His current research area is in health information systems and big data analysis. As a member of Beta Gamma Sigma, he actively seeks ways to be involved in the community. Currently he is an Associate Director for the Center for Information Technology and Business Analytics at California State University, Fullerton. He holds a Master degree in Information Systems at California State University. He is also a winner of California State Chancellor’s Doctorate Incentive Program.
